Message from the Editor-in-Chief

PSAPS versus Hearing Aids – Does it Have To Be One or the Other?

Recently the FDA in the United States had another call for submissions regarding changing the rules for Personal Sound Amplification Products or PSAPs. Since February 2009 it was legal to sell them in the United States as long as they were marketed as not being for someone with hearing loss.

The recent round of consultations (closed near the beginning of February 2014) was aimed at possibly altering that defining characteristic of PSAPs. And, I find that I am sitting somewhere in the middle on this issue.

The selling of PSAPs do not require that the prospective purchaser visit an audiologist or any other hearing health care professional. After all, PSAPs are not for those with hearing loss. Since that time, there have been arguments that the selling of PSAPs will actually help the hard of hearing consumer by starting them off and eventually these people will see an audiologist for a “real” hearing aid.

The PSAPs tend to be less expensive (and while that is true of the United States this is not always the case in Canada). One PSAP from Etymotic Research called the Bean is actually comparable in price to an entry level hearing aid that some hearing aid manufacturers make.

Another argument for a PSAP (instead of a hearing aid) is that the ultimate gain and output generated is comparable to many mid- and top-of-the-line hearing aids. With a non-occluding mold, even with high-level feedback management technology, I rarely am able to measure much in excess of 30 dB insertion gain in the 2000–3000 Hz region. Well, many PSAPs such as the Bean can also generate 25–30 dB insertion gain, despite the fact that they were manufactured and marketed to those who did not have a hearing loss.

Part of the confusion that the FDA and other regulatory agencies I am sure are having is based on the “backwards” definition – “it’s not for people with a hearing loss.” Is a 35–40 dB HL loss at 4000 Hz a hearing loss? Would we routinely fit someone with such a mild hearing loss with hearing aids? Indeed I have fit someone, but only on rare occasions when the person appeared to be functioning as if they had a much greater hearing loss. When is a hearing loss, a hearing loss?

Part of the problem is the ubiquitous audiogram that is a very blunt measuring tool that only loosely correlates with communication difficulty, especially for those with only a mild hearing loss. If audiologists stop their measurement at the level of a pure tone audiogram, it’s almost understandable that some people who may consider personal amplification, may opt for a PSAP. In many parts of the United States, a PSAP is a small fraction of the cost of personal amplification.

The other side of the coin is that people who do not see an audiologist or other hearing health care professional will lose out on what we can offer them. An audiologist can perform a full (peripheral) hearing assessment, and even perhaps, perform some more central assessment, even if it’s a rudimentary assessment of acoustic reflex thresholds (as discussed in this issue’s “Science Matters” column by Greg Noel and Steve Aiken), or more formally (as discussed in this issue’s “From the Centre Out” column by Kim Tillery). Those people who opt to purchase a PSAP instead of personal amplification will lose out on counselling regarding communication strategies (see Peter Stelmacovich’s column, “The Wired Audiologist”), hearing loss prevention strategies, and having a better understanding of their own hearing loss as a first step in the aural rehabilitation process.

From a purely technology-based perspective I am hard pressed to say that a PSAP such as the Bean is any worse than a device made by a hearing aid manufacturer. Indeed in the case of the Bean, partly because it is analog, it can handle the higher level inputs characteristic of music better than the vast majority of hearing aids in the marketplace.

In Canada, depending on the province and the provincial funding scheme for hearing aids, many PSAPs are in the same price ball park s hearing aids, so this should not be an issue. In the United States, this becomes more of an issue of access – “I can afford $600 but not $6000.” However, if more people opt for PSAPs in the United States, more money will be spent improving the technology, and given economies of scale, the price will drop. Eventually this may have ramifications for our own clients in Canada and unless we are very careful as a profession, we may see a very different professional environment in the years to come.

It will be interesting to watch how different audiology clinical facilities incorporate PSAPs into their practices – they are not mutually exclusive, and indeed one of the arguments mentioned above – PSAPs will “start off” a future consumer down the road to getting a “real” hearing aid- may be quite true. I know of several clinical practices that are quite happy to sell a PSAP knowing that down the line, they will be able to offer personal amplification for their clients.

About the Editor in Chief

Marshall is the director of research at the Musicians' Clinics of Canada and has presented and published extensively on the topics of hearing loss prevention in musicians and hearing aids for music.

Other than being the editor in chief of Canadian Audiologist, Marshall Chasin writes a regular column in the Hearing Review called Back to Basics. Some of these columns are reprinted in this issue of Canadian Audiologist with permission of the Hearing Review.